Revised December 2019
Edison State Community College
2020-2021 Parent Refusal to Complete the FAFSA
Name: __________________________________________________________ SSN: _______________________________
(Last, First, Middle)
Date of Birth: _________________ Student ID: ___________________________
You have submitted the 2020-2021 Free Application for Federal Student Aid (FAFSA) without providing parental information.
Per Federal Financial Aid Regulations, you are classified as a dependent student. Therefore, you must provide the following
documentation to our office.
Please attach this form to the requested items prior to submitting them.
A notarized statement signed by each of your parents addressing all of the following:
Student does not currently live with parent(s); and
Parent(s) stopped providing financial support as of ___________________; and
Parent(s) will not provide financial support in the future; and
Parent(s) refuse to complete the parental section of the FAFSA; and
Parent(s) are not and will not provide health and/or auto insurance for the student
Student must provide a signed detailed statement addressing all of the following:
Personal Statement of where they live and why the parent(s) will not file the FAFSA
Proof of health insurance and auto insurance or explanation of who provides coverage
If this form is approved, the student will only be eligible for Federal Direct Unsubsidized Loans at the annual grade level
maximum, $5,500 for freshman and $6,500 for sophomore, not to exceed aggregate loan limits. Complete the section below
giving Edison State Community College permission to originate the student loan. Entrance Loan Counseling and the Master
Promissory Note must be completed at before the loan will be processed.
I would like to borrow the Federal Direct Unsubsidized Loan.
Indicate the total amount of loan requested for the year: $_____________ Expected Graduation date__________
Third Party Assistance (Type/Amount Received per Semester) ___________________________________________________
Student Signature: ____________________________________________ Date: __________________________
Approved ________ Denied ________
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